FIRST EDITION PRIMARY CARE REFERRAL GUIDELINES 1
Primary Care Referral Guidelines All rights reserved. This material may be freely reproduced for educational and not for profit purposes. No reproduction by or for commercial organizations is permitted without the express written permission from the Family Medicine Specialists Association of Malaysia. You may complete your request online via our website. First Edition 2014 Family Medicine Specialists Association of Malaysia Address: Room 14, Level 5, Malaysian Medical Association Building No 124, Jalan Pahang, 53000 Kuala Lumpur Email: fms_association@yahoo.com Website: http://fms-malaysia.org ISBN: Designed by Publisher name Printed by Printing Company Disclaimer The clinical advice, referral criteria and the organizational details contained in this book refer to the Malaysian setting, unless otherwise stated. The book is intended for use by primary care practitioners and not for patients. While efforts have been made to ensure the accuracy of the information in this book, it is the responsibility of the doctor who is caring for the patient(s) to make his or her own judgment on the best treatment for the patient at that time. Although efforts are made to maintain accuracy of the information, some of the information may be outdated by the time of printing. The authors, editors and publishers cannot accept liability for information that is subsequently shown to be wrong. 2
List of Editors Dr Mastura Ismail Family Medicine Specialist Seremban 2 Health Clinic Negeri Sembilan Prof Dr Ng Chirk Jenn Consultant Family Medicine Department of Primary Care Faculty of Medicine, University Malaya Dr Adina Abdullah Senior Lecturer Department of Primary Care Faculty of Medicine, University Malaya Dr Mimi Omar Family Medicine Specialist Kelana Jaya Health Clinic Selangor List of External Reviewers Prof Dr Teng Cheong Lieng Department Family Medicine International Medical University Dr Vickneswari a/p Ayadurai Family Medicine Specialist Medan Jaya Health Clinic Petaling Jaya Prof Dr Khoo Ee Ming Department of Primary Care Medicine Faculty of Medicine University of Malaya 3
Table of Contents Foreword Preface How to use the guideline Acknowledgements List of abbreviations List of tables Content Chapter 1 Introduction Chapter 2 Aims & Objectives Chapter 3 Methodology Chapter 4 Good referral practices Chapter 5 Medicolegal implications Chapter 6 Implementation of referral guideline Chapter 7 Paediatric 7.1 Febrile convulsion 7.2 Neonatal jaundice 7.3 Acute gastroenteritis Chapter 8 Cardiology 8.1 Atrial fibrillation 8.2 Coronary heart disease 8.2.1 Angina 8.2.2 Acute myocardial infarction 8.2.3 Unstable angina/non ST Elevation MI (NSTEMI) 8.3 Heart failure 8.4 Hypertension Chapter 9 Nephrology 9.1 Chronic kidney disease 9.2 Nephrotic syndrome Chapter 10 Endocrinology 10.1 Diabetes mellitus 10.2 Obesity 10.3 Thyroid disorders Chapter 11 Gastroenterology 11.1 Dyspepsia 11.2 Jaundice in adult Chapter 12 Ophthalmology 12.1 Acute visual loss 12.2 Red eye Chapter 13 Ear, Nose & Throat 4
13.1 Dysphagia 13.2 Obstructive sleep apnoea 13.3 Vertigo Chapter 14 Orthopaedic 14.1 Back pain 14.2 Knee and hip pain (degenerative) Chapter 15 Psychiatry 15.1 Anxiety 15.2 Depression 15.3 Substance abuse Chapter 16 Urology 16.1 Haematuria 16.2 Lower urinary tract symptoms 16.3 Urinary calculi Chapter 17 Haematology 17.1 Anaemia 17.2 Haemoglobinopathies 17.3 Lymphadenopathy Chapter 18 Neurology 18.1 Headaches 18.2 Cerebrovascular accident Chapter 19 Obstetric 19.1 Gestational diabetes in pregnancy 19.2 Hypertensive disorder in pregnancy Chapter 20 Respiratory 20.1 Chronic cough 20.2 Pulmonary tuberculosis Chapter 21 Rheumatology 21.1 Osteoporosis 21.2 Gout Chapter 22 Gynaecology 22.1 Menorrhagia 22.2 Subfertility 22.3 Vaginal discharge Chapter 23 Infectious disease 23.1 Dengue 23.2 Hepatitis B 23.3 Hepatitis C 23.4 Human Immunodeficiency Virus Chapter 24 Surgery 24.1 Acute abdomen 24.2 Thyroid nodule Chapter 25 Dermatology 25.1 Acne 25.2 Psoariasis 5
Chapter 26 Child psychiatry 26.1 Autism 26.2 Learning disabilities Appendices List of contributors 6
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Foreword Congratulations to the Malaysian Family Medicine Specialists Association (FMSA), especially to the committee members, authors, reviewers and editors of the Primary Care Referral Guideline Handbook for their diligent effort to provide guidance to practitioners on the appropriate referral of patients from primary to secondary care. The decision to refer patients to specialist services in hospitals is a critical management issue. Despite its importance, there has been modest research in this area. Many retrospective evaluations of referrals seek to measure the level of appropriateness, often from one stakeholder s perspective. Careful analysis reveals that referrals are more complex. They reflect the needs and expectations of individual patients and their families, the knowledge and experience of the individual health care providers, and the range, type and level of services available locally. The contents of this booklet are the result of sound evidence and professional consensus among representatives of key stakeholder groups, involving family medicine specialists, private general practitioners and relevant hospital specialists. Primary care practitioners may use this guideline as a tool to assist in determining the best approach to manage their patients, ascertain that referral criteria are met and decide when and where to refer depending on the availability of resources and specific care at the referral centre. The patients clinical presentation and circumstances will also influence their referral. It is my hope that this Primary Care Referral Guideline Handbook will be constantly used by primary care practitioners as reference to improve the referral of patients to secondary care. Dato Seri Dr Noor Hisham bin Abdullah Director General of Health Ministry of Health, Malaysia 8